ACNE GUIDELINES:

Pathogenesis of Acne

American Academy of Dermatology

LESION PROGRESSION IN ACNE1

Sebaceous cells
Closed 1. Sebum
2. Fatty acids
comedo
• Sebum accumulates
• Follicle enlarges
• Keratinous material
Microcomedo
O P acnes
Inflammatory
builds up
Immune
Reactions
lesions
• papule
Open • Hyperproliferation
• pustule
• nodule
comedo • Keratohyaline granules 
• Disturbed desquamation

Follicar keratinocyte

MECHANISMS OF ACTION OF ACNE MEDICATIONS1

Topical retinoids: Oral isotretinoin:

 Normalize follicular  Reduce sebum production
desquamation  Normalize follicular
 Some reduce inflammatory desquamation
response  Reduce P acne indirectly
 Reduce inflammation

Hormones:
OH

 Reduce sebum production
 Normalize follicular
desquamation

Antibiotics:
 Reduce microorganisms
 Some reduce inflammatory
response

Benzoyl peroxide:
 Reduce microorganisms

Reprinted with permission from JAAD Thiboutot D et al. New insights into the management of acne: An update from the
Global Alliance to Improve Outcomes in Acne Group. Printed with permission from JAAD Gollnick H et al.Management of
Acne: A Report From a Global Alliance to Improve Outcomes in Acne J Am Acad Dermatol. 2003 Jul;49(1 Suppl):S1-37.
 STRATEGIES FOR LIMITING ANTIBIOTIC RESISTANCE IN
PROPIONIBACTERIUM ACNES AND OTHER BACTERIA2
Level of evidence: V
Combine a topical retinoid plus an antimicrobial (oral or topical); this is a
rationale choice because of the complementary modes of action that have been
shown clinically to result in
• Increased speed of response
• Greater clearing
• Enhanced efficacy against comedones and inflammatory lesions
If the addition of an antibiotic to this regimen is required:
Limit the use of antibiotics to short periods and discontinue when there is no
further improvement or the improvement is only slight
• Oral antibiotics should ideally be used for 3 mo, but 6-8 wk into treatment
might be one appropriate time point at which to assess response to antibiotics
Co-prescribe a BPO-containing product or use as washout
• BPO reduces the likelihood of antibiotic resistant P acnes emerging and
rapidly reduces the number of sensitive and resistant strains of P acnes at
the site of application
• Use BPO either concomitantly or pulsed as an antiresistance agent
• It may be helpful to use BPO for a minimum of 5-7 days between
antibiotic courses

O
Oral and topical antibiotics should not be used as monotherapy
Concurrent use of oral and topical antibiotics should be avoided, particularly
if chemically different
• Increased risk of bacterial resistance
• No synergistic actions
Do not switch antibiotics without adequate justification; when possible, use
the original antibiotic for subsequent courses if patients relapse
Use topical retinoids for maintenance therapy, with BPO added for an
antimicrobial effect if needed
Avoid use of antibiotics for maintenance therapy

References
1. Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, Shalita AR, Thiboutot D. Management
of acne: A report from a global alliance to improve outcomes in acne. J Am Acad Dermatol
2003;49(Suppl):S1-37.
2. Thiboutot D, Gollnick H, Bettoli V, et al. New insights into the management of acne: An update from the
global alliance to improve outcomes in acne group. J Am Acad Dermatol 2009;60(Suppl):S1-50.

HO

American Academy of Dermatology

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